Incorrect Affiliations
Authors: William Padula, Peter Pronovost
Journal: JAMA (2023)

In Reply "The goal is zero harms" has resonated throughout patient safety.Two decades after To Err Is Human, health care continues to face recurrences of a multitude of preventable adverse events.No guideline, policy, or public health intervention has been able to eliminate adverse events.Eldridge et al 1 illustrated this fact well-adverse event rates affect millions of people.Statistically significant shifts in rates of 21 health outcomes using big data make for publishable findings, but millions fewer adverse events implied by these rates do not comfort millions of patients still harmed.There is inherent risk in seeking health care, just like traveling by airplane.However, the airline industry has managed to reduce accident rates from more than 50 per 1 million flights in the 1960s to only 1 to 2 per 1 million flights today.The airline industry measures defects per million, whereas health care still measures adverse event cases per 1000.Top-down, systematic approaches to quality improvement combined with prospective data collection and methodologically rigorous assessment of trends has led to better outcomes in other industries, and could also benefit health care.The US spends more on treatment of the residual adverse outcomes than it does on prevention.In 2019, Shrank et al 2 estimated these costs to be $760 billion to $935 billion, whereas the savings from interventions that address waste ranged from $191 billion to $286 billion.A recent estimate is that more than $1 trillion is wasted on value defects across the US health care continuum, whereas only a fraction of $1 trillion would be needed to be spent to prevent these value defects, including adverse events, as well as inappropriate care, readmissions, and limited access to specialty care. 3Until US health systems take top-down, systematic approaches to eliminating value defects, adverse events will continue and will cost health care more than their preventive alternative.By addressing the overlapping needs to prevent multiple types of defects in value at once, health care is more likely to succeed in overcoming complexity to improve outcomes through targeted, efficient investments. 4 How do we reduce adverse event rates?It is important to reiterate taking a systems engineering approach to fixing health care problems.Investment in systems engineering balances shared accountability between health systems with local innovation by experts within health systems who understand individual communities and resources to address adverse events. 5,6n addition, quality measures of adverse events should be prospectively analyzed by multiple institutions that hold each other accountable.Engaging multiple, independent institutions with access to overlapping sets of data can reduce bias and diversify the methods used to tackle important research questions.We congratulate Eldridge and colleagues 1 for their retrospective observational study using big data to update the understanding of trends in adverse events.However, despite numerous policies to revise reimbursements and establish penalties for adverse events, patients may not perceive systems of care to be safer.We hope that as the policy makers at the Centers for Medicare & Medicaid Services reflect on these data, they will continue to innovate and reinvent their influence on the US health care system.